Reflective Practice 101 – Session #4:
Death & Dying

Background

Coping with death and dying is often challenging.  Although death has been noted to be the one great certainty of life, the dying process is replete with uncertainty, and this dichotomy can be stressful – for the individual facing death, their family members, and those who care for them.  As a topic which most people do not discuss frequently, the impending death of someone with whom we have a connection both forces us to examine our own views about death and dying and to navigate the discordance that may exist between our views and those of others. Doing this in our role as healthcare providers requires thoughtfulness, self-awareness,  and skill in order to ensure that our patients’ needs, and those of their families remain our focus during these times.

It its important that we recognize that although military healthcare providers encounter death and dying more frequently than most, the impact of these experiences on our lives is no less profound.  Indeed, these experiences, and our reactions to them, have significant implications for how we treat our patients.  It is also important to recognize that among learners in this curriculum, there is a wide range of experience with death and dying.  In past years, some students struggled to identify their personal context as it relates to Death and Dying, noting that they had no personal experience with the death and/or dying of someone with whom they had a relationship. For those of you who fall into this category, I think you will find, as have students in the past, that thinking about your perceptions of the way your family of origin and the community/ies of which you have been a member (geographical, religious, organizational, or otherwise) dealt with death and dying, including avoiding its discussion, will help you to quite readily identify the sources of your reactions to Death and Dying.

At its core, the experience of Death and Dying, for those who remain alive, includes a sense of loss. How we cope with the dying process, the death of others, and our sense of loss has significant implications for our care of patients and their families.  With this in mind, I welcome you to join us in our exploration of this important topic.

Panelists

• Dr. Wendy Bernstein is a staff Hematologist/Oncologist at Walter Reed National Military Medical Center and Associate Professor in the Department of Medicine at USU. She graduated from USU with the mighty second medical school class to graduate – the Class of 1981.
• Dr. Jinu Kamdar is a General and Trauma Surgeon who currently works in Marietta, Georgia, near Atlanta. Dr. Kamdar graduated from the Wisconsin School of Medicine and Public Health and thereafter completed residency in General Surgery at the University of Arizona before serving as a General Surgeon in the United States Navy from 1999-2010.
• Dr. Sean Simmons is a 2nd year resident in Family Medicine at Fort Belvoir Community Hospital and a Lieutenant in the U.S. Navy.  Following his graduation from the United States Naval Academy in 1998, he served as a line officer for 5 years. He thereafter resigned his commission and enlisted in the U.S. Army, serving as a member of Special Forces. He matriculated at USU in 2011 and is a graduate of the USU Class of 2015.

Assignment

Preparation for the panel
Prior to the panel, reflect on your conception of death and your past experiences with loss – including those involving the death of friends and family as well as patients, if you have had such experiences. In addition, reflect on your perspective on death of people at various ages, including children; concerns about your own competence when caring for a patient who dies; thoughts about your own mortality and fears about death; and your views on end of life care.

Reflective Essay (R.S.I.P. format)
Reaction: As stimulated by the panel and supplemental resources, identify your thoughts and reactions, including each of the following:

1. Your thoughts and feelings about being responsible for the care of someone whose decision to pursue or decline life-prolonging treatment differs from what you feel is best
2. Your reactions to two or more of the panelists’ narratives or supplemental resources that struck you as particularly poignant

*Note: When writing this section, list your affective reaction followed by 1-2 lines describing those aspects of the panel/resources that evoked your reaction.

Sources/Your Story: Through the medium of your personal narrative, explore the sources of these thoughts, feelings, and reactions. Your narrative must include specifics and be written in the first person. Your sources will likely include one or more of the following:

• your perceptions of how loss in general and death in particular were/are viewed in your family of origin, faith group, community, and among your peers (both growing up and now)
• your perceptions of how loss and death are addressed by your faith group
• your experiences to date with loss in general and death in particular
• your perceptions of how loss and death are viewed in the military and medical communities
  • one’s experiences with death and dying growing up
  • one’s views on advance directives and end of life care (to include Hospice)
  • one’s religious views
  • advance directives, etc.

Implications: Keeping in mind what your reactions and the sources of those reactions reveal about your perspective on loss and the death of your patient, analyze both the positive and negative implications of this perspective for how you might care for patients in the future.

Plan: Develop a realistic and specific plan (NOT A GOAL) to mitigate the negative and enhance the positive implications described in your Implications section.

 Objectives

By the end of the RP101 session on Loss, through written and verbal expression, students will demonstrate the ability to:

1. Identify their conception of death, their “gut reaction” to the thought of their patient’s death, and their concerns about their patient’s death to include:
   1. The personal loss entailed in the death
   2. The sense of betrayal of a personal trust
   3. Thoughts about their own mortality
   4. Their faith and spiritual beliefs
   5. Concerns about their own competence
   6. Concerns about how they might appear to their patients’ family, colleagues, others with whom they work, family and friends, and perhaps most importantly, themselves.
2. Explore the source(s) of those reactions, including:
   1. Their experiences with death at different points in your life
   2. How they perceive death to be viewed by:
      1. the family/community in which they were raised
      2. their current family/community
      3. the medical community
      4. the military community
      5. Their thoughts and feelings about death depending on:
      6. the age of a patient
      7. whether it is anticipated or unexpected
      8. the location where a patient dies (Home vs. hospital, stateside vs. deployed)
3. Analyze how their reactions to death and dying may influence, both positively and negatively their care of a patient and their family prior to their death (when death is anticipated) and after their death
4. Develop a plan (not a goal) to mitigate the negative and enhance the positive implications identified.